Thursday, May 20, 2010

Pelvic Floor Encore

Well, well, well.

By the look of my stat counter it appears I've struck a hot topic with Monday's post: Pelvic Floor Party: Kegels are NOT invited. The comments have been flying and Katy Bowman has been along with us to answer questions. Katy even posted on the topic on her own blog, Katy Says (and the post has cool graphics, so you must check it out). As the conversation ensued in the comment section I had one more question for her--one I thought deserved its own post. Here--thanks to your standing ovation--is an encore question and answer.

And here's another question for Katy on the Kegels. I don't think you're saying we write Kegels completely out of the books, are you? Would Kegels be useful, say during pregnancy and, especially immediately after childbirth when the PF has been directly traumatized? But the difference is we should not go overboard and we still have to build up the other muscles surrounding the PF. Post birth we can go from the Kegel being something we do as an exercise (a few times throughout the day versus 200 times like people have been saying) to something we do in "real time" situations (to hold back urine when we sneeze/laugh/cough/etc.)

Katy, what say you?

I can’t believe how popular this blog has become. Do you know I have friends from elementary school emailing me saying they read this posted on Facebook by people I don’t even know? And I think it is striking such a cord because 80 percent of women are facing this problem, many times silently, and are now really confused. That isn’t what we want either, is it Kara?!

So now you may be wondering “who to trust.” Why would you listen to me? Why am I saying something soooo different than other “experts”? These are all good questions, and questions you should be asking. First off, let me fill you in on the Kegel exercise. Dr. Kegel, an OBGYN, had a device that he invented that he thought would help many of his (caucasian) patients recover from the birthing process.

Before I go any further: It is well documented that Western, modern-living women have much more difficult births than their less-modernized counterparts. During these times (mid 1800’s to the 1930’s) pelvic floor damage and baby-head smashing was a problem for “civilized women,” but not the “Tinkers” (Irish gypsies) or tribal-living women. The only differences in these groups turned out to be the size of their birthing space. The size of the birthing space (the obstetrical conjugate) is created by the bony surfaces of the pelvis. The sacrum (the base of the tailbone) makes up the back side of this birthing space. The cool thing is, the sacrum is not attached to the pelvis, but floating against it. Less-civilized women (like their male counterparts) have squatted to “bathroom” their entire lives. This squatting increased their birthing space by activating the glutes (pulling the sacrum back to open the birthing space). This extra space meant less pressure on their PFs during birth (less tearing of the muscles and tendons) and required less damage to the ligaments in between the bones.

Another way to say this is the life-long habit of squatting is what prevented the PF from being damaged in the first place. The balance between the perfect amount of glute contraction and the perfect amount of PF tone give you what you want. Good pelvic (and abdominal) organ support. [Kara's Note: read Katy's post about the Hunter Gathering Mama for more about squatting for birth preparation.]

Back to Dr. Kegel. Now he had all these women who were noticing weakness and invented the Kegelizer, or something like that. It was equivalent to the Kegel-exercisers you see now. Just insert and squeeze. The squeeze improved the lost mental connection between a damaged PF and one that was firing correctly. Firing correctly meant that when the PF was done contracting, the muscles could restore to their optimal length. This part of Dr. Kegel’s research protocol has been left out and the only part that has been passed on is the contracting part.

Science Note: The muscle tissue in your PF is the same as the muscle tissue in your biceps. When you’re done realllly working your biceps, you’d like your arm to go back to its original length, right? What if, when you were done doing your curls, your elbows stayed as bent as they were when your muscles were the TIGHTEST? If you equate strong with tight, then you’d have “strong,” contracted arms with bent elbows all the time. Tight muscles. Unusable arms.

That’s not what TONE is. Tone is having the MOST strength and the MOST length.

Doing Kegels all the time will get you a TIGHT, unusable pelvic floor. This is why people’s ORGANS ARE FALLING OUT OF THEIR BODY.

Probably the worst time to be doing Kegels in the way we think “Kegels” is during pregnancy. If you looked at the research for birthing mechanics it is clear that women (especially Western women) are allowing their pelvic girdle to collapse based on our lack of glute (and calf and hamstring tension). The research shows that PFD isn’t a problem in other parts of the world.

So, all you Hot Mamas-To-Be out there HAVE TO SQUAT THREE TIMES A DAY until these joint motions come naturally. That’s how you tend to your PF before delivery. To all of you Hot Mamas out there with your birthing days behind you: Don’t let your PF gripping become stronger than your glutes.

I came up with the perfect solution, Kara. Gently tense and fully release (shy of urinating) your PF 10 times while you are in a squatting position. That way you know you are keeping all the pelvic muscles balanced.

Thank you Katy, again, for such eye-opening and SENSIBLE information. Now, let's take a vote. The exercise Katy describes as a replacement for traditional Kegels, I'm going to hereby refer to as the Bowman Squat. Everyone raise your hand if you agree.

An hour after originally posting I'm back because I've had an hour to process this and have a few thoughts. What I'm hearing is (this sounds like I'm in a counseling session, which I almost feel like I need after such apocalyptic information) that Kegels aren't inherently bad, that Dr. Kegel meant well but our puritanic based society just got a little too anal (literally) about them. I mean, I know I for one think that if 10 push ups are good, then 20 are better. If I can do a sprint triathlon, then heck let's go for the Ironman! So it's easy to see how we heard Dr. Kegel (which became every OB on the planet) telling us to squeeze, but we ignored that bit about releasing. And now I'm going deep, folks... but who among us has an easy time "letting go." That, right there, is what childbirth is all about: letting our body open up and let go. But the majority of women can't do it without numbing drugs and interventions. Open up and let go? Huh, what? No, letting go just doesn't come natural to us in our society. We can clench and squeeze and get nice and tightly wound, but ask us to let go? I think what Katy is saying is that our pelvic floor needs balance, we can't overlook the benefits of lengthening and stretching while we're busy strengthening. The exercise of letting go is always a good one to practice in any aspect of life. And I'm telling you, to relax your pelvic floor just shy of urinating--holy cow!--it's super relaxing; like sinking into a tub of warm water... wait, that was water, right?

43 comments:

I agree! Bowman squat is far more sensible than a straight Kegel. I went for physio to rebalance my PF and like Katy says, the most important thing and most difficult thing for me to learn was to relax my PF, not tighten it.

These last two posts have totally rocked my world! Thank you SO MUCH for this! It makes a lot of sense to me. I'm pregnant with my third and have been losing control of my pelvic floor more & more. Therefore I've been doing more kegels. But things were getting worse, not better. And now I know why!!! Back to squatting (why did I quit? *When* did I quit?). So thanks for saving this mama from more pee-sneezes at the least!

As a counseling student, I've become aware of valuable information about pelvic floor relaxation in trauma work and in bodily health (the idea being that if we live in a constantly stressed state, in the "fight or flight" sympathetic nervous system, our bodies will burn out, hence the need for an effective way to relax). The pelvic floor is the only part of the body completely surrounded by muscle, so by relaxing the PF for 20-30 seconds, the rest of the body is triggered to relax and switch into the parasympathetic nervous system. "Being able to live in a state of “non anxious presence” (NAP) is key to managing future potential crises and traumas. NAP is not something that can be mastered in one session, but is something that needs to be practiced and used when life is not traumatic. It is a technique used to facilitate the PNS, so that we may stay relaxed and calm. Good gauge of a NAP is a relaxed pelvic floor. Being in this state allows one to be empathetic, compassionate and bear witness asa spectator. It is about relaxed mindfulness and comfort in ones own body." (Noel Holdsworth DNH, APRN-BC, CTS www.ejhealers.com)

Leah F--THAT is fascinating. Seriously, when I relaxed my PF all the way like Katy says, my eyes almost rolled back in my head I felt so loose all over. I'm intrigued by the holistic ramifications; how one facet of our bodies can impact so much.

In teaching prenatal yoga classes, I taught a version of pelvic floor lifts with the image of going up in an elevator to the 5th floor, then coming back down - all the way to the basement. This tightening and releasing of pelvic floor muscles is vital, not only during pregnancy, but throughout a woman's life. I did have to caution some students to limit the exercise to two to three times a day, as some do tend to think "more is better."

I'm a childbirth educator and got this link from a client. It's rocked my BRAIN. I do teach the "elevator" style kegel, along with squats, as well as a kegel where you tighten then release the perineum so that it bulges out and is loose and relaxed. I would love to see the original research/references on this! Can you point to where it is? I am going to experiment with the Bowman squat this very weekend!!thanks!

I would like to see the research as well. Dh and I are (or were) both scientists, so I need to see studies. I found some that contradict the premise of being anti-kegel. Katy, can you share your research on why kegels are bad? Biofeedback and p/t have science to back them up in helping. I have a prolapse, so would like to learn more before I give up something that *has* shown me improvement-properly done kegels.

I am not a professional in the least. I am a mom of three children, and I have suffered with bladder control issues for most of my life. I am a little confused though about some of the comments that say they read kegels are bad. I think the point of the second post was to clarify that they AREN'T bad, they should just be done in moderation, and to take it one step further, if they are going to be done, they would work better in a squat position. We, as a society, tend to overdo pretty much everything. And kegels are no exception.

I am going to start doing the Bowman squat, and see what sort of results I end up with. It would be nice to not have to worry about peeing when I sneeze, cough, laugh, BREATHE lol.

Thank you Desiree~ I'm a pelvic floor physical therapist and would love to see the 'science' that Katy is talking about. We know very well that 'kegel's' work! But I also agree that pelvic positioning and squatting are important. Ladies, please take everything you read with a grain of salt- there are things that Katy said that scientifically untrue, so don't give up on everything else you've ever learned because one person says it is so!!

I feel a bit better about this follow-up post... I feel that Katy's message is more balanced here. Katy, you're not saying that kegels are "bad," per se, just that people tend to over-do. I agree. Many of my patients (I'm a women's health PT) with pelvic pain have incredibly hyperactive/tense (and weak) pelvic floors. Relaxation is key --- but again, so is knowing how to contract when functionally necessary. So whether it be via "Bowman Squats" or CORRECT kegels (a PFM contraction followed by a complete relaxation) we can all agree that pelvic floor health is the result of well-coordinated pelvic floor muscles that know how to contract when needed, and know how to relax the rest of the time. Take a look at my blog for some great relaxation exercises... www.pelvichealthplus.com.

Hello! Great posts everyone! I wanted to post some additional information to help clarify the science behind the recommendation of a squat for optimal pelvic floor health: http://www.katysays.com/2010/06/10/kegel-saga-continuesthe-video/

I can assure you that as a biomechanist (physicist of soft tissue), I am adhering to the scientific laws of both physiology and physics. Journal articles are not the end all of scientific data, they are simply what has been researched and leave out, of course, what has not. The correctly applied "scientific method" question to ask is for the data disproving the fact that kegels make the pelvic floor weak over long term. Or researching showing the correlation between pelvic telemetry (measurements of the pelvis) don't affect PFD, which of course, there is. The problem with journal articles is people tend to read journals that fall within their field. PTs read PT journals, but probably not Biomechanical engineering ones. We all have a perspective and it's all valid depending on our scope of knowledge!

One more post: The articles cited by Ryan and Libby, were an interesting choice. The first two articles didn't test the effectiveness of Kegels (?) and the second two concluded that while PFMT (Pelvic Floor Muscle Training) has shown possible short-term effectiveness, long term studies need to be done to show that PFMT is an effective long-term treatment...kind of my point :)

I'm not at all defensive or unexpecting of the reactions that are happening now, but the word "truth" is a dangerous one to use when speaking of human body science. It implies that your belief in something could prevent the forward movement of the actual science, and in the long run, we want women to have the best options, even if it means changing old institutions.Peace out,Katy

Katy Bowman makes alot of sense. The pelvic floor is not a "one trick pony". Tighter is not better. The pelvic floor works best when it is strong, supple and well coordinated with other core muscles (like diaphragm and transversus abdominus) and balanced by strong/flexible glutes, groin and quadriceps. For people who cannot tolerate a deep squat (hip replacements, arthritis, neurological disorders and plenty of other situations), using the breath to release the pelvic floor is a powerful technique.

I'm pretty sure a have a prolapse. Going to the midwife this week. I ordered the video - really hoping for positive results. I know my pelvis needs to be aligned- my hips and back are always killing me. Question, though: Due to an accident, my range of motion in one knee is only 90 degrees. If I can't squat, what else can I do to strengthen my glutes?

I teach antenatal yoga in the uk and I have found this a very useful discussion. A lot of what Katy has said sounds familiar from my training. I love that I can post this to my clients and it is written in a way that (I think) is relatively easy to digest and in a style that makes you WANT to read it. Not dry and boring.

I got this article from my midwife Karly Nutall, and am very grateful. I recently had a baby( my third), am in my forties and was diagnosed with cysto and rectocele; considered surgery and went through the whole roller coaster with that because I am a very holistic person, had my last baby at home, in the bathtub; etc..FOr those who want research and scientific 'evidence' there is a book out there called Saving the whole woman by CHristine Kent, and she discusses the same issues thoroughly as Miss Bowman does. I highly recommend it. SHe goes into the physiology, lifestyle changes and has a dvd with exercises to strengthen the pelvic floor. In all honesty, I liked the book much better than the dvd because the exercises are too fast and based on irish dances, which I couldn't do to save my life, or my lower body, nevertheless, the book is well written and persuasive about why kegels don't work to strengthen the PF.

OMG! I'm 60 yrs old with vag and rec prolapse.Probably due to 3 childbirths and hard-core weight lifting squats several years ago.I have been seeing a P.T. for 4 months now and we cannot get my PF stronger and I've been doing kegels (10 in a row quickly and 10 slowly 3X/d!! It ain't workin' for me! SO she's been hooking a vag probe up to a tens unit to increase the brain/vag response but it is so expensive that I'm now supposed to buy one for $400 so I can do this at home. I refuse to have surgery and I've heard horror stories of pesaries. . Only have prolapse-no painful sex(thank God!, or stress incontinence. Urge incontinence if I drink even one cup of coffee. I will need to re-read your info and purchase your DVD.Hope I'm not too late! Am fortunate I stumbled upon your site! Thank you, Pam

Not to confuse the issue, but to introduce some fun, I presume everyone is familiar with the concept of the connection between the pelvic floor and your tongue (careful, its a family site)?

Seriously...sit feet flat on the floor, pelvis square on a chair, spine softly erect. Now, sensing the space between your sitting bones (ischial tuberosities), gently begin to press your tongue against the back of your teeth and watch what happens to your PF as you increase the pressure, and then watch as you slowly release (old Feldenkrais lesson).

Not only that, but what you are thinking and what you believe in the moment directly impacts your breathing pattern, which also sets tone in the PF (for the evidence crowds see O'Sullivan PB, Beales DJ. Man Ther. 2007.Aug;12 (3):209-18. Epub 2006 Aug 17.)

So feet on the floor, soften the tongue and exhale...happy PF's everyone!

So I've heard this theory before from a some nurse (Christine Kent I think?) and I'm curious. Katy, since you're a scientist, will we see some causation research done? I would be interested in a controlled study that examines the effect of squats and posture on the eventual pelvic organ prolapse occurance. All those correlations are neat, but I want to see something more concrete.

Also as a side note, I think pelvic strength is great. But, as a scientist myself, I know that everything has an elasticity limit, even muscle. Pregnancy and birth can provide enough force for some muscle to never go back to it's strength or length. Look at your stretchmarks ladies - some women have more elastic skin. Nothing you can do to change it. Bottom line: don't blame yourself for your pelvic floor problems

Hi Anonymous,The mechanical failure you are speaking of is called CREEP (really, that's what it's called!) and has nothing to do with PFD (this is well researched, so with a little leg work anyone can see the extreme difference between the failure of skin vs. muscle). In other words, stretch marks have no scientific purpose in a discussion about PFD.The incorrect notion that the structure is inherently weak and the cause of PFD is really the problem in a nutshell (thanks for bringing it out to discuss, though!), and is really undermining Women's Health.

Regarding research, there is, quite extensively, research on the role pelvic bony alignment contributes to PFD, but no one is talking about it, so there it sits in journals...

Of course I wasn't suggesting that skin stretches the same way as muscle - just pointing out that everthing has an elastic limit. It is entirely possible to be too flexible and hence more prone to injury (my gymnast of a brother-in-law lived it for many years).

So what is in your opinion the yield strength of the pelvic floor? At what stress level will it no longer go back to its shape? Are you saying there isn't one? That seems to defy the laws of physics.

I don't think telling women that they can be inherently prone to pfd is undermining their health. Are dentists undermining their patients when they tell them they've inhertited bad teeth? Sometimes you can brush three times a day and floss and you'll still have tooth decay. It's just reality. Not that you shouldn't take care of yourself. But I find blaming the victim to be more undermining, actually.

Again, there are no studies that show posture/squats prevent PFD. There are some correlation papers. Where is the causation data. There is a big difference. I think it's time for a peer reviewed controlled study. It should be easy and inexpensive enough to do. You've developed a theory - it needs proof.

Thanks for mentioning me, Ileana and Anonymous, as Katy can count her “team of one” amongst the over 4,000 members at wholewoman.com, where women have been doing this work since 2003. Many thousands of copies of Saving the Whole Woman have been sold to women, doctors and all sorts of health practitioners.

The people who fund large studies generally do not want to know what reverses the very disorder that is the bread and butter of gynecology. They will be conducted eventually, and it is not as if we have no data. Check out the paper, “Genital prolapse: a legacy of the West?” in the Australian and New Zealand Journal of Obstetrics and Gynaecology. More importantly are natural and real-time testimonials of women themselves, which were never possible before the great democratizing power of the internet. Maintaining the natural shape of the spine is the only way the pelvic organ support system properly functions.

Regarding connective tissue, an anti-inflammatory diet has also been discovered to be a major player in prolapse stabilization and reversal. The evolved human body is extremely stable, and unrepaired congenital breaks in DNA rare. Prolapse and incontinence are highly dynamic conditions that respond to postural and lifestyle change.

I think research on this is a GREAT idea! If anyone out there is interested in funding it, please contact me ASAP! We need to investigate this study: http://www.ncbi.nlm.nih.gov/pubmed/18651881 a bit more it would appear. Also, short-term kegel studies conclude with the fact that more research is needed before deciding if they are, in fact effective.

If you would like to wait a few years for evidence showing that strengthening your sacral stabilizing muscles to optimize your PF muscles based on the laws of Newtonian Physics,biomechanical muscle modeling, and the force/length graph, then you are completely welcome! For women who have been doing kegels the last few years and are prolapsing, perhaps they are interested in a more timely solution? Everyone gets to choose, which is what makes life so great!And, there's always surgery, don't you agree Anonymous?

As a health practitioner, I have followed this blog with some interest. In an intelligent discussion, Anonymous provides an odd voice, without the self-respect to identify the source of strange and illogical arguments backed only by having identified one’s self as “a scientist.”Where Bowman has presented a logical, coherent and viable solution for a pervasive health problem, your contribution has been to question the scientific validity of the approach by comparing PFD with stretch marks (, ladies) and "inherited bad teeth."

It’s a sad state of affairs when a “scientist” - real or self-perceived - is so quick to dismiss an unfamiliar therapy when the “correlation” evidence is compelling, the contrary evidence is non-existent, and the cost of implementation is zero.

I lost all bladder control after the birth of my first child, I did PFs religiously for weeks until I only had slight bladder leakage when I needed to go to the toilet and then I gave up doing them and only do them randomly. I cannot run or jump, which really bothers me as I used to run long distances and love it.I think what Katy says makes a lot of sense. My pelvis was out of alignment (and still is a bit after pregnancy) when I got Chiro and Bowen therapy to help me straighten up a bit and not be so swayed forward, I noticed an immediate improvement in less bladder leakage. I definitely believe there is a correlation between posture and continence.

As a Pre & Post Fitness Specialist, I find this topic very interesting. I work with women daily to help them strengthen their "core" before and long after pregnancy...which includes No crunches, but instead transverse ab work, posture strengthening exercises, splinting (if they have diastasis recti), pelvic floor, lower back and glute work. What Katy is saying makes sense, kegels are ok in moderation but glute work needs to be done. There is also a theory out there that women need to be doing 500 or more trans ab exercises/day to get their diastasis to close. My program is more in moderation and works on progressive exercises so the client can build up strength to recondition the damaged core without having to do "ridiculous amounts of trans abs and kegels".

Well said Katy, I look forward to reading more of your work! I can't wait to see more research done on this topic.

Wow...I wish I'd had this information in my younger, more flexible days. I'm now 46 and have given birth 13 times. I am trying to get myself in shape but now have the disadvantage of osteo arthritis in my right knee, which makes me unable to bend it very far and makes squatting low impossible! :( Any suggestions for me?

I know this is a "family" blog but in reading about releasing the pelvic floor I was instantly reminded of the same necessity in achieving G-spot orgasms. As mentioned in the post, it can be difficult for many women to release the pelvic floor. It has been a rather recent discovery for me (even at age 39) but one I am delighted with. Perhaps this would be another blog topic - if you think there might be a connection and it's not to "risky" =} I know I wish someone had told me about it sooner.

Question for Katy: When you talk about how kegels are not really the best thing for PF you always refer to kegels as 'squeezing'. My Physical Therapist had me think of kegels more as lifting. Think of raising from anus to urethra etc. She actually told me that my kegels were too much squeezing and not enough lifting.

Does your theory fit in with this too? i.e what I mean is that - is the 'lifting' kegel just as bad/tightening as the one where the squeeze is more emphasized?

I agree! Bowman squat is far more sensible than a straight Kegel. I went for physio to rebalance my PF and like Katy says, the most important thing and most difficult thing for me to learn was to relax my PF, not tighten it.

Love all of this information and it totally makes sense!! I have very nice muscles and could probably write my name holding a pen, BUT I did start prolapsing. I kept hearing kegels, kegels, kegels, but that didn't help. I did start doing whole body vibration (TurboSonicUSA.com) and concentrated on squats and relaxing and my uterus did go back up perfectly and my bladder issues were resolved. I also was able to relax and enjoy activities with my husband...

Now, I'm pregnant and put whole body vibration on hiatus due to unknown effects on the fetus, but I did begin prolapsing to the point of my cervix being about an inch out of my vagina, among other issues. Again, I got the kegels, kegels, kegels... all the while telling my midwife we have relations 2-3 times a day and I work them well.

And all of what Katy says totally makes sense!!! I'm going back to all the squats and work I was doing before and will report back.

Hi! I am a sufferer of Pelvic floor dysfunction, mainly with a hypertonic pelvic muscle. The information on pelvic health is very limited out there, so I am really glad to have come across this blog.I am learning to do the squat now. Thank You Katy, you are awesome !

I just had a "smack-my-forehead moment." Is it POSSIBLE that this lack of space in the pelvic area can cause or contribute to breech presentation?? I am petite and had a large baby that was head down and then turned breech about 36 weeks (never going back). Ended up with a c/s even after trying a natural birth for 36 hours. So, I'm wondering if I was doomed from the get-go due to a lack of proper space. AND could I actually create more space for my next baby? Finger crossed...getting excited!!

Hi I have been doing my pelvic floor exercises as recommended by the doctor and physio. I'm fine most of the time but not when I run. I do long distance running and I leak or even flood as I get tired towards the latter part or the run. I have had 5 births and had urinary incontinence and bed wetting when I was a child. I also suffer from a lack of butt. I have recently had a proceedure to realign my coccyx. It has relived the pain I was suffering but my exercise stress induced incontinence seems to be worse. Do you think the coccyx realignment has made it worse?

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This blog isn't about weight loss or acquiring the perfect body, it's about the absurdities we moms face when we're trying to be mom, wife, employee (or employer), daughter, sister, friend, and the many other roles we take on; while making fitness fit into our lives. As a former endurance athlete, I'm trying to stay in shape while I raise my three young daughters and son. Finding the time and the means to exercise isn't just about me, though. I also want to be a good role model and help my children grow up active and healthy.

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About This Mama

I'm mom to 11-year-old twin girls, another daughter who is 9 and a 5-year-old son. I'm also co-author of the book, "Hot (Sweaty) Mamas: Five Secrets to Life as a Fit Mom," (www.hotsweatymamas.com) and the children's book series for the Go! Go! Sports Girls (www.gogosportsgirls.com). As you might guess, I enjoy being active, especially (but not limited to) running, biking, swimming, and yoga.